Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5198_Библиотеки_им_академика_М_И_Перельмана.pdf
Contents
xiii
31 Special Trauma Cases and Damage Control Surgery . . . . . . . . . . . . . . . . . . . . . . .253
Caitlyn McCall and Lisa L. Schlitzkus
32 Trauma Team Decision-Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Nada Gawad, Nori L. Bradley, Larissa Roux, and S. Morad Hameed
33 Emergency Critical Care Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277
Paul B. McBeth and S. Morad Hameed
34 REBOA and Novel Hemorrhage Control Methods . . . . . . . . . . . . . . . . . . . . . . . . . 287
Nori L. Bradley, Shaun Cowan, and Megan Brenner
35 Interventional Radiology in Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Andrew Kiraly, Kris Peet, and Jason Wong
36 Communication and Leadership in the Operating Room . . . . . . . . . . . . . . . . . . . . 309
Thomas Blanks and Simon Denning
37 Pain Management in the Trauma Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Javier Webar, Tom Hall, and Sebastian Layera
38 Trauma Resuscitation in the Health Information Technology Age . . . . . . . . . . . . 323
Jenna Kroeker, Barak Raguan, Olivia Hunter, Patricia Balmes, Larissa Roux,
Harvey G. Hawes, and S. Morad Hameed
39 Telemedicine and Future Innovation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .333
Corry J. Kucik, J. Jonas Carmichael, and William P. Mulvoy III
40 Human Factors of Teleresuscitation and Telementoring . . . . . . . . . . . . . . . . . . . . . 339
Lauren Hampton and Lawrence Marshall Gillman
Part IV Specialized Trauma Populations
41 Trauma in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .345
Alexandra Marseu, Michelle L. Morais, Lua R. Eiriksson, and Paul T. Engels
42 Medical Comorbidities and Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Harvey G. Hawes and Renée-Anne Poirier
43 Advanced Neuromonitoring for Moderate and Severe
Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Carleen Batson, Logan Froese, Alwyn Gomez, Amanjyot Singh Sainbhi,
and Frederick A. Zeiler
Part V Emergency Ultrasound and Trauma Imaging
44 Basic Trauma Ultrasound. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Markus Ziesmann, Andrew W. Kirkpatrick, and Lawrence Marshall Gillman
45 Trauma Ultrasound: Beyond the FAST Examination . . . . . . . . . . . . . . . . . . . . . . .389
Michael Blaivas, Ashot E. Sargsyan, and Dimitrios Karakitsos
46 Imaging in the Stable Trauma Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Bradley S. Moffat and Neil G. Parry
47 Advanced Considerations in Cross- Sectional Imaging in Trauma . . . . . . . . . . . . . 407
Signy Holmes
xiv
Part VI Tactical Emergency and Disaster Medicine
48 Disaster Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Michelangelo Bortolin and Gregory R. Ciottone
49 The Multi-casualty Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .423
Daniel Roizblatt, Amin Madani, Tarek Razek, and Kosar Khwaja
50 Critical Incident Team Dynamics and Logistics . . . . . . . . . . . . . . . . . . . . . . . . . . .431
Jeremy W. Cannon, Jose L. Pascual, and Lewis J. Kaplan
51 Terrorism and Urban Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Jose L. Pascual, Jeremy W. Cannon, and Lewis J. Kaplan
52 Tactical Emergency Medicine, Procedures and Point-of-Care
Evaluation in Austere Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Michael Blaivas, Ashot E. Sargsyan, and Dimitrios Karakitsos
53 An Introduction to Tactical Medicine Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . .457
William Guse, Shaun Cowan, Andrew Beckett, and Kenji Inaba
54 Hypothermia and the Trauma Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
Susan Marjorie Roberts, Sean Lynch, Dean Gubler, and Anthony J. LaPorta
55 Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 479
Adam Padalko, Rae Paulene Spiwak, and Sarvesh Logsetty
Contents
56 War Zones and Biological Weapons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Jason D. Heiner and William Hurley
57 Nuclear Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Mansoor Ali Khan and Heidi L. Frankel
58 Trauma and Surgical Capabilities for Space Exploration . . . . . . . . . . . . . . . . . . . 497
David J. Alexander
59 Logistical Transformation of Healthcare Systems in the COVID-19 Era . . . . . . . 511
Jaffar A. Al-Tawq and Ziad A. Memish
60 Trauma in the Setting of a Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Niels D. Martin and Lily Tung
Part VII Trauma Team Education
61 Designing a Simulation Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Jason Park, Reagan L. Robertson, and Ashley S. Vergis
62 Simulation Scenario Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
J. Damian Paton-Gay, Peter G. Brindley, and Lawrence Marshall Gillman
63 Constructive Debriefing for Trauma Team Education . . . . . . . . . . . . . . . . . . . . . .547
Adam Cheng, Vincent Grant, and Naminder Sandhu
64 Program Evaluation and Assessment of Learning . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Vicki R. LeBlanc and Walter Tavares
65 Teaching Technical and Procedural Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
Garrett G. R. J. Johnson and Ashley S. Vergis
66 Competency-Based Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
Brett Mador
Contents
xv
67 Simulation Center Design, Development, and Management . . . . . . . . . . . . . . . . . 575
Susan Carter and Tariq Al Shanteer
68 The Story of “Hyper-Realism”: From Hollywood to the Bedside . . . . . . . . . . . . . 591
Kit Lavell and Lawrence Marshall Gillman
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
Part I
Trauma Team Preparation
A Culture ofSafety: Evolution
oftheS.T.A.R.T.T.Course
LawrenceMarshall Gillman, J.DamianPaton-Gay,
PaulT.Engels, andSandyWidder
1
The Simulated Trauma and Resuscitation Team Training
(S.T.A.R.T.T.) Course is a multidisciplinary trauma team
training course designed to teach non-technical (crisis
resource management) skills to all trauma team members
involved in the care of the multi-injured patient, including
prehospital personnel (emergency medical technicians and
paramedics), nurses, respiratory therapists, physician assistants, nurse practitioners, emergency physicians, anaesthetists and surgeons.
History
The S.T.A.R.T.T. course evolved from humble beginnings.
The course foundation was initially devised in 2010 by two
keen staff surgeons (LG and SW) who had completed their
Trauma/Critical Care training and realized there was a need
for optimizing trauma team dynamics during resuscitations.
With the burgeoning national Royal College Acute Critical
Events Simulation (ACES) course (now under the auspices
of the Canadian Critical Care Society) [1] and monthly local
crisis simulations, critical care training had embraced Crisis
Resource Management (CRM) principles; however, trauma
L. Marshall Gillman (*)
Departments of Surgery Section of General Surgery, University
of Manitoba, Winnipeg, MB, Canada
Internal Medicine Section of Critical Care, University of Manitoba,
Winnipeg, MB, Canada
e-mail: Lawrence.Gillman@umanitoba.ca
J. D. Paton-Gay · S. Widder
Department of Surgery, University of Alberta,
Edmonton, AB, Canada
e-mail: patongay@ualberta.ca
P. T. Engels
Departments of Surgery and Critical Care Medicine,
McMaster University, Hamilton, ON, Canada
e-mail: engelsp@mcmaster.ca
and surgical training was lagging behind. The course was
started at their local institutions in Edmonton and Winnipeg
as a way to improve general surgery resident trauma training
specically focussing on non-technical skills training. The
success of this concept locally quickly led to the educational
expansion to a national platform, but prior to implementation, the foundations needed to be established.
A needs analysis of general surgery program directors
across the country was undertaken. The response rate was
64.7% (11 of 17). Only a minority of programs had CRM
training and trauma simulation as part of their local curricula. The vast majority saw value in this training, however,
and supported the creation of a national curriculum and
training program [2].
This led to the formation of the S.T.A.R.T.T. course committee and a discussion about the format, content and curriculum of the initial pilot course. It quickly became clear
that training residents in isolation would do little to improve
the actual functioning of the full trauma team. While many
CRM training programs included non-physician team members in their simulations, most were confederates whose
roles were to support resident learning but not necessarily act
as learners. This prompted us to expand the planned
S.T.A.R.T.T. course to a multidisciplinary model where all
participants enter each simulation blindly and are treated as
equal participants. Not only was the premise to enhance team
trust, but also to reect the reality of the unpredictable nature
of trauma, highlighting team dynamics that were not previously apparent. The inaugural S.T.A.R.T.T. course was held
in conjunction with the Canadian Surgery Forum in Calgary
on September 12, 2012. Twenty general surgery residents
(PGY 1–6), ve practicing nurses and four respiratory therapists participated in the course supported by eleven instructors. These participants represented eight universities from
six different Canadian provinces, with all the respiratory
therapists and nurses from local hospitals. The course was
overwhelmingly well received with 97.5% of participants
rating the course as “good” or “excellent” and 97.5% recom-
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_1
3
4
L. Marshall Gillman et al.
mending it to others. On pre- and post-course testing, all
groups also showed a signicant improvement in attitudes
towards CRM principles specically within the domains of
teamwork and safety climate [2].
While the bulk of the feedback was positive, there were
constructive criticisms as well. Most importantly, even
though the non-physician participants were told they were
equal participants, some felt the simulation cases, and
debriefs were still physician-centric, and they did not truly
feel like true participants and team members. Over the ensuing courses, extensive work was done to overhaul the scenarios, including obtaining input from non-physician
stakeholders. Learning objectives and tasks were created for
each participating discipline and unique scenario designs
were created, including distance simulations and staggered
entry scenarios in order to engage non-physician participants
and improve the experience for all. Not only did these
changes accomplish these goals, they broadened the learning
objectives and added important layers to the debriefs [3].
These will be discussed in more detail later in the chapter on
Multidisciplinary Simulation Design.
One of the most well received and benecial changes we
made was to our instructor assignments. As is common
with simulation courses, we initially had instructors
assigned to each simulation scenario and the participants
rotated as a team from scenario to scenario. While this
allowed instructors to become familiar with their stations
the participants felt they were receiving signicant repetition in the content of the debrief from scenario to scenario.
We therefore made a change, assigning one of our senior
instructors, termed a “team coach” or “team navigator”, to
spend the day with each team. Other instructors were
assigned to individual simulation stations. This had multiple immediate benets. First, it allowed a single instructor
to get to know the group for the duration of the day. The
coach was tasked with leading all the debriefs and therefore
could build on lessons learned from the previous scenario
while helping their team focus on areas of weakness or new
areas in subsequent scenarios. It also built rapport between
the debriefer and the team members, and ensured a culture
of safety so that the debriefer could understand personalities, unique team dynamics, and bring out comments from
all team members. We also ensured that our team coaches
had received formal debrieng training to ensure they were
skilled to control the room and the post simulation debrief
maintaining a balanced discussion that identied and closed
performance gaps.
As the course content developed, two distinct versions of
the course emerged. The rst was the standard course,
involving physicians, respiratory therapists, nurses and phy-
sician assistants. The second was an expanded course incorporating pre-hospital personnel as part of the participating
groups. This addition was extremely well received as it not
only incorporated mass casualty management and transport
issues, it also added an additional layer of communication
and handover. The format brought together two distinct
groups of practitioners (hospital and prehospital personnel)
that frequently interact and work together but rarely, if ever,
train together [4].
In 2017, we introduced the surgical cut suit, otherwise
known as “Human Worn Partial Task Surgical Simulators”
(Strategic Operations, Inc.), as a routine component of the
course. This one-piece zip-up suit is worn by standardized
patients and takes the place of classic mannequin-based simulation. The cut suit allows for procedures including cricothyroidotomy, chest tube insertion, laparotomy and even ED
thoracotomy to be performed directly (and safely) on a live,
talking actor, enhancing both conceptual and physical realism. This addition was similarly met with overwhelming
support, as more than 70% of participants reported the suits
as an essential part of the course and more than 90% reported
the suits as valuable to the course and an improvement in
course realism [5].
Documented Outcomes
To date, we have held 17 courses in major trauma centres
across Canada and an international course in Melbourne,
Australia. We have trained over 300 trauma providers and
have more than 50 trained instructors. We held our rst
French language course in Quebec City. The challenge of
running a communication course for francophone participants coached by predominantly anglophone faculty was a
welcome and rewarding learning experience for the course
leadership [6].
The ideal venue for S.T.A.R.T.T. courses remains an
area of debate. The majority of S.T.A.R.T.T. courses to
date have been held at large national and international
meetings. However, we have also run a number of local
courses, notably in Winnipeg and Montreal, involving
local trauma teams. Running smaller local courses has the
advantage of training teams that work together on a regular basis, improving the camaraderie and non-technical
skills of established teams while fostering further local
work and innovation. On the opposite side, holding
courses at larger national and international meetings
brings together participants (and experts) from multiple
centres, each offering their own local avour and expertise with the ability for participants to return to their own
1 A Culture ofSafety: Evolution oftheS.T.A.R.T.T.Course
centres with new shared knowledge. The reality is that
there is no perfect model. Using local courses to reinvigorate the culture of safety and ongoing quality improvement at the site level, while using larger national courses
to share information and maintain a cohesive trauma community are likely both worthwhile endeavours.
Future Direction
With the COVID-19 pandemic, the S.T.A.R.T.T. course
reached a crossroads. The feasibility of a large-scale, inperson, training curriculum was unclear in that challenging environment. Thankfully it seems we have weathered
the pandemic and restarting larger courses at national
and international meetings seems possible again.
However, the COVID pandemic has allowed us to consider other shifts in philosophy for the S.T.A.R.T.T.
course. As with all challenges, there is an opportunity
for innovation. We are currently looking at hybrid models using virtual platforms to offer simulation over distance and training local trauma teams from multiple
institutions simultaneously [7]. This may allow us to
share knowledge across the national and international
communities, while allowing local teams to hone their
responses within the culture and environment of their
home facilities. With technological development, other
potential avenues of pursuit may include courses held in
virtual reality environments, allowing for participants
across vast distances to simulate together in a virtual
classroom.
Regardless of how S.T.A.R.T.T. evolves to meet this new
challenge, the need for continual training and updating of
our trauma practitioners remains. After all, trauma care is the
ultimate high-performance team sport, and no team gets better without dedicated practice.
5
Key Points
• A trauma crisis resource management team training
course adds important skills not currently available
elsewhere.
• The structure and venue of this course will need to
continue to evolve as this training becomes more
widely available and ubiquitous.
References
1. Canadian Critical Care Society. About National Acute Critical
Event Simulation (N-ACES). https://www.canadiancriticalcare.
org/N- ACES. Accessed 9 Nov 2022.
2. Ziesmann MT, Widder S, Park J, Kortbeek JB, Brindley P, Hameed
M, etal. S.T.A.R.T.T.: development of a national, multidisciplinary
trauma crisis resource management curriculum-results from the
pilot course. J Trauma Acute Care Surg. 2013;75:753–8. https://doi.
org/10.1097/TA.0b013e3182a925df.
3. Gillman LM, Brindley P, Paton-Gay JD, Engels PT, Park J, Vergis
A, et al. Simulated Trauma and Resuscitation Team Training
course-evolution of a multidisciplinary trauma crisis resource management simulation course. Am J Surg. 2016;212:188–1e3. https://
doi.org/10.1016/j.amjsurg.2015.07.024.
4. Gillman LM, Martin D, Engels PT, Brindley P, Widder S.French
C.S.T.A.R.T.T. plus: addition of prehospital personnel to a national
multidisciplinary crisis resource management trauma team training
course. Can J Surg. 2015;58:010915–5.
5. Johnson GGRJ, Brindley PG, Gillman LM.Fidelity in surgical simulation: further lessons from the S.T.A.R.T.T. course. Can J Surg.
2020;63:E161–3. https://doi.org/10.1503/cjs.017818.
6. Trauma Simulation in Bilingual Canada. Insurmountable barrier or
unexpected strength? Insights from the rst bilingual S.T.A.R.T.T.
course. Can J Surg. 2016;59:80–2. https://doi.org/10.1503/
cjs.014115.
7. Johnson GGRJ, Beaumont J, Paton-Gay JD, Widder S, Gillman
LM. Multidisciplinary, multisite trauma team training during
COVID-19: lessons from the rst virtual E-S.T.A.R.T.T. course. Can
J Surg. 2021;64(6):E609–12. https://doi.org/10.1503/cjs.009921.
The Genesis ofCrew Resource
Management: TheNASA Experience
DavidJ.Alexander
2
Humble Beginnings
The National Aeronautics and Space Administration (NASA)
has been intimately involved with the process of Crew Resource
Management (CRM) and one of the early innovators of the systematic procedures to eliminate human error in the cockpit.
The rst effort was the development of the aviation checklist.
This was due to the crash of the Boeing Model 229 aircraft on
October 30th, 1935. The Boeing Model 229 was an extremely
complex aircraft for the time. It had many revolutionary design
elements incorporated. The pilot, who had never own the
Model 229, had neglected to release the elevator lock prior to
takeoff. The Boeing chief test pilot aboard the aircraft, Leslie
Tower, realized the error once airborne. He attempted to release
the lock but was too late to save the doomed aircraft. The design
was in serious jeopardy after the crash. The press had labeled
the aircraft as too complex to y. Army Air Corps ofcers
pleaded to proceed with the project and eventually 12 aircraft
were delivered to the 2nd Bombardment Wing at Langley
Aireld in Virginia. It was emphasized to the pilots that any
further accidents would result in the cancellation of further
orders. The pilots came together and developed four checklists.
These were the Take- off, Flight, Pre-landing, and After Landing
checklists. They eventually proved that the Model 229 was not
“too much aircraft for a man to y”; it had systems more complex than any one man’s memory. These checklists were the
assurance that no item was forgotten. These 12 aircraft went on
to safely y 1.8million miles without a serious accident. The
Model 229 went on to be developed as the B-17. It was one of
the workhorse bombers of World War II and helped to destroy
Nazi Germany’s war industries. The checklist was then integrated into subsequent Air Corps aircraft and the civilian airline
industry.
Human error as a cause for an accident was placed in the
public eye again on the night of December 29th, 1972. An
D. J. Alexander (*)
Johnson Space Center, Houston, TX, USA
e-mail: david.j.alexander@nasa.gov
Eastern Airlines Lockheed L-1011, Flight 401 would be a
sentinel event in safety. Flight 401 was en route from JFK
Airport, New York, to Miami International Airport. The
Lockheed L-1011 had rolled out of the factory only four
months previously. This particular ight carried 163 passengers and 13 crewmembers. The journey was routine up until
11:32 pm. The aircraft was on approach to Miami
International, and the landing gear was lowered. The landing gear indicator was not illuminated, indicating the gear
was not down and locked. The landing gear was cycled
again, and the illuminator still did not light. The light on the
indicator was burned out, and the cockpit crew began replacing the bulb. The crew discontinued the approach and began
a circling pattern to work on this problem. The second ofcer was sent into the lower avionics bay to view through a
small window and conrm the gear was down. The aircraft
autopilot was activated to maintain 2000 ft. During this
time, the pilot accidently leaned against the yoke (control
column) and changed the modes on the autopilot from altitude hold to CWS (Control Wheel Steering—in which the
pilot controlled the pitch of that aircraft). This forward pressure also started the aircraft to descend. After descending
250 ft, a C-cord alarm was sounded in the cockpit. This
alarm was designed to alert the crew that they had descended
from their assigned altitude. The frustrated, fatigued crew
who were concentrating only on the burned out light did not
notice the alarm. The engineer was not on the ight deck as
well and could not have heard the alarm from the avionics
bay. The plane was over the Everglades at night, and therefore, there was no ground references to indicate the plane
had descended. In fty seconds, the aircraft was now down
to 1000ft. The co-pilot then initiated a 180 degree turn to
maintain a holding pattern and noticed the discrepancy in
altitude. This triggered the following conversation .
Co-pilot: We did something to the altitude.
Pilot: What?
Co-pilot: We’re still at 2000ft, right?
Pilot: Hey—what’s happening here?
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_2
7
8
D. J. Alexander
Ten seconds later, the aircraft impacted the Everglades.
This resulted in the deaths of 101 persons and was the rst
accident of a wide-bodied airliner. At that time, it was the
second deadliest single aircraft disaster in the United
States [1–4].
Another accident around this same time period highlighted human error in the cockpit. United Airlines Flight
173 (UAL 173) was making its nal approach to Portland
International Airport after a routine ight on December 28,
1978 [5]. The aircraft ran out of fuel and crashed into a residential area, killing eight passengers and two crew members
and seriously injuring 23 others. While circling, the rst ofcer and ight engineer told the pilot that the plane was running low on fuel. The pilot ignored the warnings of his junior
ofcers. These and other accidents aroused the interest publically in accidents due to human error.
In all of the cases, the aircrafts were mechanically sound;
the crews were experienced and technically competent. The
system at the time simply did not catch mistakes in time to
prevent these fatal errors. In 1978, the Military Inspector
General determined that poor crew interactions were a major
factor in aircraft accidents. NASA then led the way to change
the aviation community to prevent these accidents from
occurring. In 1979, NASA conducted the Resource
Management on the Flightdeck workshop at the Ames
Research Center [6, 7]. NASA had for many years been conducting research into human factors and performance in
aviation since the early 1970s at the Ames Research Center.
In 1973, interviews with aircrews were conducted, and this
highlighted the lack of training for airline Captains in leadership. H.P.Ruffel-Smith (1979) conducted a 747 simulatorbased study on human behavior [8]. He found that in both
routine and emergency simulations, the better the cockpit
resources were utilized and using effective crew communications, the better the performance in the cockpit. Several other
studies suggested that incorporating “Crew Resource
Management” into routine ight operations training would
greatly aid in preventing these accidents. During the workshop, it was soon discovered that 60–80% of aviation accidents were the result of human error. Clearly the aviation
industry had to change. After another NASA/Federal
Aviation Administration (FAA) workshop conducted in
January 1981, the FAA began incorporating a CRM platform
into its regulatory program. United Airlines was the rst to
add CRM into its training syllabus in 1981.
A New Paradigm Is Born
Crew Resource Management does not focus on technical
aptitude or skills. CRM focuses on cognitive and interpersonal communication needed to organize a complex aviation
environment. Cognitive skills focus on situational awareness,
planning, and decision-making. Situational awareness provides an organized way to recognize salient factors and conditions that affect the safe operation of the aircraft. Planning
takes the decision construction process across all phases of
the ight. This also incorporates subordinate input into the
decision formation process but still maintains a hierarchical
structure with the Captain retaining authority and responsibility for the ight. Interpersonal skills concentrate on communications and team building. Essential to CRM is
communication. Research has proven that good communication not only transfers accurate information but helps to build
a unied understanding of the problems at hand. It helps
everyone to build a mental model of the environment and
enhances situational awareness. Team building incorporates
the entire crew’s skills and experience, resulting in the combined efforts far exceeding the capability of one individual.
Emotional climate and stress management skills are also
taught in CRM training. Research showed that the creation of
a positive tone on the ight deck enhanced the cognitive and
interpersonal prociencies of the crew. Stress management in
the cockpit can be managed by an organizational culture that
efciently assigns tasks and establishes priorities. This also
incorporates the empowerment of subordinates by training
them in the skills that will enable them to take on additional
responsibility when the circumstances demand it.
The airlines embraced CRM training as well as the military. NASA took these concepts and incorporated them into
the shuttle training program. One aspect of CRM was simulation training in the management of complex contingency operations that occur in spaceight. These had been incorporated
into the NASA culture since the earliest phases of spaceight.
From Mercury through today’s International Space Station
training, simulators have been a mainstay of spaceight practice. NASA has also learned hard lessons from its failures. The
Challenger accident highlighted several lapses in the NASA
“Safety Culture” that contributed to the disaster. The investigation highlighted NASA’s and Morton Thiokol’s failure to
respond to the design aw of the O-rings in the Solid Rocket
boosters. Rather than redesign the joint, it was dened as an
acceptable ight risk. This was the “Normalization of
Deviancy” or the violation of standards of practice repeatedly
such that they actually become routine over time. This occurs
by errors, lapses, or mistakes that go unattended, unappreciated, or unresolved for an extended period of time. The report
also impugned the decision to launch. It cited numerous failures in communication that resulted in a decision to launch
51-L.The decision was based on “incomplete and sometimes
misleading information, a conict between engineering data
and management judgments, and a NASA management structure that permitted internal ight safety problems to bypass
key Shuttle managers” [9] .
2 The Genesis ofCrew Resource Management: TheNASA Experience
9
Attention once again focused on the attitude of NASA
management toward safety issues in 2003, after the Space
Shuttle Columbia loss. The Columbia Accident Investigation
Board (CAIB) deduced that NASA had not incorporated the
lessons of Challenger. One highlight was that the agency had
not set up a truly independent ofce for safety oversight. The
CAIB concluded that in this area, “NASA’s response to the
Rogers Commission did not meet the Commission’s intent”
[10]. The CAIB believed that “the causes of the institutional
failure responsible for Challenger have not been xed” [10].
They declared that the same “awed decision making process” that had culminated in the Challenger accident was at
fault for Columbia’s destruction. The Challenger and
Columbia accidents are now used as case studies in how several concepts in CRM broke down. The lessons for NASA
were breakdowns in communication, lapses in group decision
making and most importantly, revealed the dangers of groupthink (in which the desire for conformity or amity in a group
results in a deviant or awed decision-making conclusion).
NASA continues to improve the CRM process. The shuttle crews incorporated CRM directly into their training.
These Shuttle Transportation System (STS) crews underwent numerous case simulations of normal and emergent
situations. These incorporated the lessons learned from aviation and the shuttle accidents. These were incorporated into
CRM for the entire shuttle operational teams. The crews
were together for several years prior to launching. This
included not only the mission’s onboard crewmembers, but
the Mission Control Teams dedicated to the particular missions. Numerous crew bonding activities to promote communication and team building were incorporated in to
training regimens. Events such as the National Environmental
Leadership School (NOLS) classes to teach leadership
became important in astronaut training. These sessions
incorporate leadership curriculum, outdoor ethics, and wilderness skills to help develop good leadership and communication. NASA management also undergoes CRM training to
produce a true safety culture. These lessons are still integral
to the International Space Station training and the future mission culture of NASA.
Medicine has also learned from these experiences in aviation. Helmreich and Schafer proposed using the NASAinspired Crew Resource Management from the airline industry
in operating rooms [11]. Subsequent to that in 1999, Sexton
etal. compared ight crew interactions with operating room
staff. This extensive multiyear study showed a remarkable difference in the attitudes about teamwork. The surgical staff
showed that the surgical attendings and residents reported
high levels of teamwork, but the ancillary staff (anesthesiology attendings, residents, nurses, and OR nurses) reported
exceptionally low levels of teamwork. A signicant amount of
attending surgeons preferred the use of steep hierarchies (with
junior team members being limited in questioning the decisions and actions of a superior). This was in stark contrast to
the airline crews, instilled with the Crew Resource Management
styles, who 94% preferred the at hierarchies (in which junior
members are encouraged to voice concerns about the senior
members choices and decisions) [12]. The study also revealed
the attitudes toward fatigue. A vast majority of the surgical
staff agreed with the statement “Even when fatigued, I perform effectively during critical times.” In stark contrast, only
26% of the ight crews agreed with that statement [12]. In
2000, a landmark report from the Institutes of Medicine (IOM)
was released that sparked a large amount of public debate. The
report “To Err Is Human: Building a Safer Health System”
examined medical errors in healthcare systems. The report
cited results from Colorado and Utah that up to 44,000 people
died due to medical errors. It then went on to refer to one
NewYork study, which indicated that up to 98,000 died due to
errors in the medical system [12]. The report then concluded
emphatically “healthcare is a decade or more behind other
high-risk industries in its attention to ensuring basic safety.”
These lead to public outcries which subsequently lead to
President Bill Clinton executing an executive order to require
federal departments to develop safer practices in healthcare
[13]. This lead to the Joint Commission on Accreditation for
Healthcare Organizations (JCAHO) to support aviation teamwork applications in training programs for hospitals [14, 15].
The Sexton study and several other papers around that
time triggered numerous changes to training programs,
which incorporated aviation-inspired Crew Resource
Management. Critical areas such as the Emergency
Departments, Operating Suites, and Labor/Delivery were
identied as those areas that could benet from CRM training [16–18]. Anesthesiology incidents that were related to
human error were proclaimed to be as high as 65–70% [15].
This prompted the VA Palo Alto Healthcare System and
Stanford University to develop the Anesthesia Crisis
Resource Management (ACRM) system based on CRM [16,
19]. The Army Research Laboratory and Dynamics Research
Corporation developed the MedTeams behavior-based teamwork system. This drove military-based aviation experience
into the Emergency Medicine training [18]. This system was
expanded into labor and delivery units. The system eventually drove specic training and assessment tools incorporated into the Emergency Team Coordination Course. Similar
to aviation CRM, the entire philosophy was centered on
avoiding errors, ensnaring errors when they occurred, and
mitigating all the consequences of decisions and actions that
may have been taken in error. Peer monitoring is critical in
all the medical CRM approaches. This insures maintaining
adequate situational awareness during essential dynamic
medical procedures. This then aids in incorporating good
practices into procedures and improving training programs.